Bradford, James NEW YORK STATE DEPARTMENT OF HEALTH' 5-1( U
Vital Records Section Burial - Transit Permit
Name First Middle Last Sep`
--S11eYGS ZI:co.Uen LS/2ti9FORM !Y9te
Date of De th Age If Veteran of U.S. Armed Forces,
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}- P -ce of Death /- I Hospital, Institution or7
ADOown or Village OLi.-,,�s / fa2C-� I Street Address 2 C - e- A i
0 'anner of Death Natural Cause ❑Accident 0 Homicide 0 Suicide r7 Undetermined 0 Pending
W Circumstances Investigation
WMedical Certifier Name Title
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h Certificate Filed District Number`" t R�gi tuber
Ci own or Village Lp t1„A.1.r / ,iu .c
OBurial Date /L / I Cemetery o rematory� .r
// Z I -- �' . id El 0/IA-)Entombment _
0 Address
^remation v IGa.`_ /1-4=1. 0 t/ % e3 /V
Date Place Removed v�
Z ❑Removal and/or Held
t and/or Address
inHold
0 Date Point of
N0 Transportation Shipment
O by Common Destination
Carrier
Disinterment Date Cemetery Address
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Reinterment Date Cemetery Address
Permit Issued to t I Registration Number
Name of Funeral Home AG\JoCU y D. r�C Kt:, F fait"i (: I HOC) C. I i Jt_ -_
Address
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Name of Funeral Firm Making Disposition or to Whom 1— Remains Remains are Shipped, If Other than Above
Address
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O. Permission is hereby granted to dispose of the human remains described above as indicated.
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Date Issued /1/5 1/2. Registrar of Vital Statistics GO CA k,y'p (A) -
G ]� ^� � i i� (signature)
District Number 5tO / Place __-_-C1l�:MS 1, P'
i- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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W Date of Disposition ii-c-It Place of Disposition t•�c J u,� rre.,,tfor,...._
2 (address)
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CD
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0 (section) f-(lot number),-, (grave number)
p Name of Sexton or Person in Char e of Premises 4 r,) tM�i '
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W Signature !_4i __- _____ Title (i2C nt 1 Ull
(over)
DOH-1555 (02/2004)